Tonsillectomy : indication, procedure & tonsil removal
Tonsillectomy
We have described in article :
Indication of tonsillectomy
Procedure of tonsillectomy
Post-operative order of tonsillectomy operation
Complications of tonsillectomy operations
Types of haemorrhage after tonsillectomy
Management of reactionary haemorrhage after tonsillectomy
Indications of unilateral tonsillectomy :
- Unilateral tonsillar enlargement suspected of malignancy.
- Suspected malignant ulcer of the tonsil.
- Benign tumours from the tonsil.
- In glossopharyngeal neuralgia for nerve section.
- Removal of styloid process.
Procedure of tonsillectomy :
Instruments :
- Endotracheal tube.
- Revolving tool.
- Draffin’s Bipod.
- Boyle Davis mouth gag
- Tonsillar snare.
- Tonsil replacement forceps.
- Artery forceps.
- Blade.
Positions of the patients : (Rose’s Position/Tonsillectomy position)
- Supine position.
- Head extended by placing a pillow under the shoulders. A rubber ring is placed under the to stabilize it.
Positions of the surgeon : Head end of the operation table on a revolving tool.
Anaesthesia : General anaesthesia with endotracheal intubation
Steps of operation :
- Sterile draping and cleaning.
- Opening of the mouth by introducing a Boyle.
- Fixation of the mouth gag with the help of Draffin’s Bipod.
- Suction and cleaning of the oral cavity, hypopharynx and a pack is given within the hypopharynx not to allow introducing blood in the stomach (as blood is a highly emetic).
- Holding of tonsils and drawn medially by tonsil holding forceps.
- Incision: On the whitish line (capsule) over the anterior pillar or junction from upper to lower pole.
- Dissection of tonsils-from upper to lower pole.
- Cutting and crushing of the lower pole of tonsils, this is done by tonsillar snare.
- Searching of bleeding points- caught and ligated.
- In the same way the other side, tonsillectomy is done.
- Again suction and cleaning of the oral cavity and hypopharynx and then removal of the pa Never remove the hypopharyngeal pack before suction.
Post-operative order of tonsillectomy operation :
Immediate general care :
- Keep the patient in coma position until fully recovered from anaesthesia.
- Keep a watch on bleeding from the nose and mouth.
- Keep check on vital signs, e.g. pulse, respiration and blood pressure.
Diet :
- When patient is fully recovered he is permitted to take liquids, e.g. cold milk or ice cream.
- Sucking of ice cubes gives relief from pain.
- Diet is gradually built from soft to solid food. a day.
Oral hygiene :
- Patient is given Condy’s or salt water gargles three to four times a day.
- A mouth wash with plain water after every feed helps to keep the mouth clean.
Analgesics for relieve of pain.
Antibiotics : A suitable antibiotic can be given orally.
Patient is usually sent home 24 h after operation unless there is some complication.
Patient can resume his normal duties within 2 weeks.
Complications of tonsillectomy operation :
Immediate :
- Primary haemorrhage.
- Reactionary haemorrhage
- Injury to the tonsillar pillars, uvula, soft palate, tongue or superior constrictor muscles, teeth.
- Aspiration of blood.
- Facial oedema.
- Surgical emphysema.
Delayed :
- Secondary haemorrhage.
- Infection: Parapharyngeal abscess, otitis media.
- Lung complications.
- Scarring of soft palate & pillars
- Tonsillar remnants.
- Hypertrophy of lingual tonsil.
Types of harmorrhage after tonsillectomy :
Primary haemorrhage : Haemorrhage during the operation.
Reactionary haemorrhage : Bleeding within 24 hours of tonsillectomy operation.
Secondary haemorrhage : Haemorrhage after 24 hours till the wounds heal, usually within 3 to 10% postoperative day.
Primary haemorrhage after tonsillectomy :
- Primary haemorrhage occurs at the time of operation.
- It can be controlled by : Pressure, ligation, electrocoagulation of the bleeding vesscls.
Management of Reactionary haemorrhage after tonsilliectomy :
Reactionary haemorrhage : Bleeding within 24 hours of the operation, but commonly within 5-6 hours is called reactionary haemorrhage.
Causes :
- Failure to ligate the all bleeding points.
- Slipping of ligature.
- Collapsed vessels opening up in the post-operative period.
- Failure of vessels to contract and retract following crushing.
- Dislodgment of the clot due to raised blood pressure.
- Relaxation of the stretched faucal tissue.
- In case of local anaesthesia, as the effect of adrenaline wears off, the vessels dilate
Clinical features :
- Dribbling of blood.
- Vomiting of clotted blood.
- Repeated swallowing
- Increase pulse rate.
- Decrease blood pressure
- Cold and calms extremities
- Shallow respiration
- Oral cavity full of blood clot
- Large colt in the tonsillar fossa.
Treatment:
- Assessment of the patient-pulse, blood pressure, respiratory rate and temperature.
- If the patient is in shock-intravenous fluid and blood transfusion.
- Mouth is opened by tongue depressor and removal of clot by long arterial forceps and gauze pack which is given not more than 10 minutes. If not stopped-
.If oozing-H2O2, soaked gauze to be applied.
.If sprouting-Bleeding vessel to be ligated under general anaesthesia.
- Other treatment : Antibiotic, analgesic, vitamin.
Secondary haemorrhage :
Definition : Any haemorrhage after 24 hours in the post-operative period is called secondary haemorrhage but the usual time is on the 5th to 10th post-operative days.
Cause :
- Secondary infection in the tonsillar fossa.
- Separation of slough.
Clinical features :
- Bleeding-slight at first, later frank ooze occurs.
- Blood stained salvia.
- Fever
- Pain on swallowing
- Foetor oris.
- In the tonsillar fossa-infected colt & unhealthy slough.
Investigation : Throat swab for culture & sensitivity.
Treatment :
- Remove the infected clot or slough by long arterial forceps.
- H2O2, gurgle (local treatment only): So all the clots and sloughs will come out clearly.
- Systemic antibiotics. Should be changed what was given before and give high dose broad spectrum antibiotics.
- Sedative: Diazepam
- Analgesics for relieve of pain.
- Rest in bed.
- Gauze piece in the fossa soaked with H2O2, if the above procedures are failed (48 hours will remain there) [Gauze pack-in between anterior and posterior pillar and 2-3 stitches (over sewing the pillars) are given under general anaesthesia]
- Blood transfusion is necessary in severe cases.
Pre-operative investigations :
- Complete blood count.
- Serum creatinine.
- Blood urea.
- Blood sugar: Fasting/ Random/ Post-prandial..
- Urine R/M/E.
- Chest X-ray.
- ECG.
- Blood grouping & Rh typing.
- HBsAg
b) Patient is not fit for tonsillectomy: Please write contraindications of tonsillectomy.
c) Monitoring of a post tonsillectomy patient: Please write from above discussion.
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